{"paper_id":"336ead04-c98d-41d0-a372-597de8bd11cd","body_text":"1\n1 A survey of patient and public perceptions and awareness of SARS-CoV-2-related risks \n2 among participants in India and South Africa \n3\n4 Short Title: Perceptions and awareness of SARS-CoV-2-related risks\n5\n6 Oluchi Mbamalu 1*, Surya Surendran2#, Vrinda Nampoothiri3, Candice Bonaconsa1, Fabia Edathadathil3, \n7 Nina Zhu 4, Vanessa Carter5, Helen Lambert6, Carolyn Tarrant7, Raheelah Ahmad4,8, Adrian Brink9, \n8 Ebrahim Steenkamp 10, Alison Holmes4, Sanjeev Singh3, Esmita Charani1,4, Marc Mendelson1\n9\n10 1 Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, \n11 University of Cape Town, Cape Town, South Africa. \n12 2 Health Systems and Equity, The George Institute for Global Health, New Delhi, India. \n13 3 Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita \n14 Vishwa Vidyapeetham, Kochi – Kerala, India. \n15 4 National Institute for Health Research, Health Protection Research Unit in Healthcare Associated \n16 Infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, \n17 London, United Kingdom.\n18 5 Health Communication and Social Media, Johannesburg, South Africa.\n19 6 Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, \n20 United Kingdom.\n21 7 Department of Health Sciences, University of Leicester, Leicester, United Kingdom.\n22 8 Division of Health Services Research and Management, School of Health Sciences, City, University \n23 of London, United Kingdom.\n24 9 Division of Medical Microbiology, Faculty of Health Sciences, National Health Laboratory Service, \n25 Groote Schuur Hospital, University of Cape Town, South Africa.\n26 10 Statistical Consulting Unit, Department of Statistical Sciences, University of Cape Town, South \n27 Africa.\n28\n29 * Corresponding author\n30    Oluchi Mbamalu\n31    Division of Infectious Diseases & HIV Medicine\n32    Department of Medicine\n33    University of Cape Town\n34    G26/68 Groote Schuur Hospital Observatory,7925\n35    Cape Town, South Africa\n36    Tel: +27 79 794 9346\n37    Email: oluchi.mbamalu@uct.ac.za \n38   \n39  Alternative corresponding author\n40    Marc Mendelson\n41    Division of Infectious Diseases & HIV Medicine\n42    Department of Medicine\n43    University of Cape Town\n44    G26/68 Groote Schuur Hospital Observatory,7925\n45    Cape Town, South Africa\n46    Tel: +27 79 794 9346\n47    Email: marc.mendelson@uct.ac.za \n48\n49\n50 # This research was conducted when the author was affiliated with the Department of Infection \n51 Control and Epidemiology at Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi \n52 – Kerala, India.\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n2\n53 ABSTRACT\n54 A cross-sectional survey was performed among the adult population of participating \n55 countries, India and South Africa. The purpose of this study was to explore perceptions and \n56 awareness of SARS-CoV-2-related risks in the relevant countries. The main outcome measures \n57 were the proportion of participants aware of SARS-CoV-2, and their perception of infection \n58 risks.\n59 Self-administered questionnaires were used to collect data via a web- and paper-based survey \n60 over three months. For data capturing, Microsoft Excel was employed, and descriptive \n61 statistics used for presenting data. Pearson’s Chi-squared test was used to assess \n62 relationships between variables, and a p-value less than 0.05 was considered significant.\n63 There were 844 respondents (India: n=660, South Africa: n=184; response rate 87.6%), with a \n64 61.1% vs 38.3% female to male ratio. Post-high-school or university education was the lowest \n65 qualification reported by most respondents in India (77.3%) and South Africa (79.3%). Sources \n66 of information about the pandemic were usually media and journal publications (73.2%), \n67 social media (64.6%), family and friends (47.7%) and government websites (46.2%). Most \n68 respondents correctly identified infection prevention measures (such as physical distancing, \n69 mask use), with 90.0% reporting improved hand hygiene practices since the pandemic. \n70 Hesitancy or refusal to accept the SARS-CoV-2 vaccine was reported among 17.9% and 50.9% \n71 of respondents in India and South Africa, respectively. Reasons cited included rushed vaccine \n72 development and the futility of vaccines for what respondents considered a self-limiting flu-\n73 like illness. \n74 Respondents identified public health promotion measures for SARS-CoV-2. Reported \n75 hesitancy to the up-take of SARS-CoV-2 vaccines was much higher in South Africa. Vaccination \n76 campaigns should consider robust public engagement and contextually fit communication \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n3\n77 strategies with multimodal, participatory online and offline initiatives to address public \n78 concerns, specifically towards vaccines developed for this pandemic and general vaccine \n79 hesitancy.\n80 Key words: Awareness, Infection prevention, Perception, COVID-19, Vaccination\n81\n82\n83\n84\n85\n86\n87\n88\n89\n90\n91\n92\n93\n94\n95\n96\n97\n98\n99\n100\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n4\n101 INTRODUCTION \n102 The SARS-CoV-2 pandemic has highlighted the importance of infection prevention at \n103 individual and community levels. The World Health Organization (WHO) has indicated that for \n104 public health infection prevention measures to be successful, all members of society \n105 (communities and professional groups included) should be fully engaged [1]. These measures \n106 include but are not limited to physical distancing, masking, hand hygiene, avoiding poorly \n107 ventilated indoor spaces, and isolation/quarantine if infected or exposed. For efficient buy-in \n108 and contribution to these measures, individuals should understand the risks, mode of viral \n109 transmission, and consequences of infection. As such, the success of infection prevention \n110 measures depends on individual and community-level awareness and the adoption of \n111 infection prevention behaviours, which in turn depends on their perceptions and cognizance \n112 of risk. \n113 While effective public engagement has been highlighted as key to gaining buy-in [2-4], \n114 additional research is needed to explore public awareness, perceptions and behaviours about \n115 SARS-CoV-2 and how these may influence adherence to public health measures, especially in \n116 low- and middle-income countries (LMIC). India (lower-middle-income) and South Africa \n117 (upper-middle-income) [5] are countries with emerging economies where the SARS-CoV-2 \n118 pandemic has had a significant impact [6]. Redeploying the capacity within an existing \n119 research collaboration across participating sites in these two countries [7, 8] , we investigated \n120 the public’s perceptions and awareness of SARS-CoV-2-related risks and infection prevention \n121 practices through analysis of data contributed by participants across the two countries. \n122\n123\n124\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n5\n125 METHODS \n126 Study design \n127 We conducted a cross-sectional web- and paper-based survey. Data were collected using a \n128 self-administered questionnaire. Any adult member (over 18 years old) of the public, who \n129 provided informed consent before participation, was eligible to participate. \n130\n131 Study development \n132 The study development followed the STROBE cross-sectional reporting guidelines [9], as \n133 shown in Table 1 under Supporting Information.\n134\n135 Table 1 (Supporting Information): Reporting Checklist for cross-sectional study\n136\n137  The research team – made up of pharmacists, physicians, nurses, social scientists, patient \n138 advocate and public engagement specialist, and quantitative data analysts – designed a 42-\n139 question survey to elicit information on the public’s knowledge, perceptions and awareness \n140 of SARS-CoV-2 infection risks. The 4-part survey included participant demographics, general \n141 knowledge of SARS-CoV-2, perceived risks and barriers, and self-efficacy. In South Africa, \n142 survey questions and participant information leaflets were translated into IsiZulu, IsiXhosa \n143 and Afrikaans languages, whereas in India, the paper-based survey was translated into \n144 Malayalam for local distribution. The survey was piloted with members of the public, and \n145 relevant revisions were made before dissemination.\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n6\n146 Study settings and participant recruitment\n147 The survey was open for participation by any member of the public over a 3-month duration. \n148 Voluntary response sampling was utilized. All invited individuals received participant \n149 information leaflets, and those willing to participate had to provide informed consent before \n150 commencing the survey. Participation was voluntary across both countries. \n151 In South Africa, the survey was available online in three languages – IsiXhosa, Afrikaans and \n152 English. In India, the survey was available online in the English language, and in the paper \n153 format in two languages, English and Malayalam.\n154\n155 Data collection\n156 Data collection took place from 15 September to 15 December 2020 and coincided with the \n157 first wave of the SARS-CoV-2 pandemic in India and the beginning of the second wave in South \n158 Africa. In South Africa, the survey was available online via Qualtric. In India, in addition to the \n159 online platform in English, paper surveys (in English and Malayalam) were also distributed \n160 among participants (patients, patient carers and/or visitors) at the study site (hospital) in \n161 Kerala.  \n162\n163 Ethics Statement\n164 The study was approved by the relevant human research ethics committees at the Amrita \n165 Institute of Health Sciences, Kerala, India (Ref: IRB-AIMS-2020-232) and the University of Cape \n166 Town, South Africa (Ref: 311/2020). Formal consent was obtained prior to participation in the \n167 survey. For the online and paper versions of the survey, consent was indicated by the \n168 participant ticking the relevant box for consent on the survey form. \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n7\n169 Statistical analysis\n170 Data from participants who completed the paper-based format were captured in a Microsoft \n171 (MS) Excel file and codes assigned, while data of participants who completed the online form \n172 were exported to MS Excel. The data from the paper-based and online versions of the survey \n173 were cleaned and combined. \n174 Descriptive statistics were used to report participant characteristics and survey responses. \n175 The underlying outcomes were awareness of the pandemic, perceived threats and barriers, \n176 and self-efficacy. Responses were captured as categorical variables, reported as percentages \n177 of received feedback for each item of interest (missing data were excluded) or, where \n178 possible, data were scaled from strongly agree to strongly disagree. Pearson’s Chi-squared \n179 test was used to assess relationships between variables, and p < 0.05 was considered \n180 statistically significant.\n181\n182 RESULTS \n183 Participant demographics\n184 There was a total of 844 respondents (660 participants from India and 184 participants from \n185 South Africa). There were 318 respondents to the online survey and 342 patients or patient \n186 carer respondents to the paper survey in India. The response rate for the online survey was \n187 87.6% (502/573), calculated as the ratio of participants who clicked on the survey link versus \n188 those who commenced participation. The response rate for the paper version of the survey \n189 could not be estimated, as respondents returned a higher number of the completed survey \n190 forms than the initial number disseminated, indicating the forms had been copied and shared \n191 more widely. \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n8\n192 There were more female (515/844, 61.0%) than male (323/844, 38.3%) respondents (Table \n193 1). Three entries for age were excluded (one was invalid with two selections and two were \n194 missing), resulting in a total response of 657 for age entries. Most of the respondents in India \n195 and South Africa were in the 20-29-year (310; [n=657] 47.2%) and 40-49-year (57; 31.0%) age \n196 groups, respectively.\n197 Table 1 Self-reported respondent demographics\nCharacteristic India South Africa Total\nn (%) n (%) n (%)\nCountry of residence 660 (78.2) 184 (21.8) 844 (100)\nGender (n=660) (n=184) (n=844)\nMale 285 (43.2) 38 (20.7) 323 (38.3)\nFemale 369 (55.9) 146 (79.3) 515 (61.1)\nPrefer not to say 5 (0.8) 0 5 (0.6)\nMissing 1 (0.2) 0 0\nAge n = 657 (%) n = 184 (%) n = 841 (%)\nYounger than 20 years 41 (6.2) 7 (3.8) 48 (5.7)\n20 to 29 years 657 (47.2) 14 (7.6) 324 (38.5)\n30 to 39 years 133 (20.2) 21 (11.4) 154 (18.3)\n40 to 49 years 82 (12.5) 57 (31.0) 139 (16.5)\n50 to 59 years 49 (7.5) 49 (26.6) 98 (11.7)\n60 to 69 years 30 (4.6) 27 (14.7) 57 (6.8)\n70 years and older 12 (1.8) 9 (4.9) 21 (2.5)\nRegular water supply n = 650 (%) n = 176 (%) n = 826 (%)\nYes 560 (86.2) 172 (97.7) 732 (88.6)\nNo 90 (13.8) 4 (2.3) 94 (11.4)\nEducation n = 653 (%) n = 175 (%) n = 828 (%)\nPrimary schooling 28 (4.3) 1 (0.5) 29 (3.5)\nSecondary schooling 113 (17.3) 25 (13.6) 138 (16.7)\nPost-high school 291 (44.6) 96 (52.2) 387 (46.7)\nPost-graduate degree 219 (33.5) 50 (27.2) 269 (32.5)\nOther 2 (0.3) 3 (1.6) 5 (0.6)\nEmployment n = 633 (%) n = 166 (%) n = 799 (%)\nStudent 135 (21.3) 5 (3.0) 140 (17.5)\nEmployed, part time 35 (5.5) 11 (6.6) 46 (5.8)\nEmployed, full time 249 (39.3) 62 (37.3) 311 (38.9)\nSelf-employed 47 (7.4) 50 (30.1) 97 (12.1)\nRetired/Pensioner 27 (4.3) 19 (11.4) 46 (5.8)\nI was furloughed/laid off during the lockdown 8 (1.3) 5 (3.0) 13 (1.6)\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n9\nUnemployed 122 (19.3) 13 (7.8) 135 (16.9)\nOther 10 (1.6) 1 (0.6) 11 (1.4)\n198\n199 The percentage of student respondents was higher in India (21.3%, 135/633) than South \n200 Africa (3.0%, 5/166). Unemployment was higher among respondents in India (19.3%, \n201 122/163) than in South Africa (7.8%, 13/166), while there were more self-employed (30.1%, \n202 50/166) and retired (11.4%, 19/166) respondents in South Africa. \n203\n204  Knowledge and concerns of SARS-CoV-2 transmission and infection\n205 Reported sources of SARS-CoV-2 information, completed by 652 and 172 participants in India \n206 and South Africa, respectively, are shown in Figures 1a and 1b. Media and journal publications \n207 were the most common sources of information, along with social media, family and friends, \n208 and government websites. On social media across both countries, Facebook®, WhatsApp® \n209 and YouTube® were the most frequently used sites for information about the pandemic.  \n210\n211 Figure 1a Respondents’ sources of SARS-CoV-2 information (traditional and social \n212 media) in India (n=652)\n213\n214 Figure 1b Respondents’ sources of SARS-CoV-2 information (traditional and social \n215 media) in South Africa (n=172)\n216\n217 In Table 2, the respondents’ knowledge of SARS-CoV-2 transmission routes, infection course \n218 and prevention/management options is summarised. The primary route of SARS-CoV-2 \n219 transmission identified was nasal/oral droplets, airborne particles, and infected body fluids. \n220 More than half of the respondents also demonstrated knowledge of SARS-CoV-2 incubation \n221 and symptom manifestation, quarantine objectives, and general duration of isolation for \n222 infected patients. \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n10\n223 Table 2 Respondent’s knowledge and experiences of the pandemic\nResponse (%) \nKnowledge of SARS-CoV-2 India South Africa Total\nMajor routes of transmission\nInfected bodily fluids 426/516 (82.6) 55/119 (46.2) 481/635 (75.7)\nNasal or oral droplets 555/591 (93.9) 158/165 (95.8) 713/756 (94.3)\nAirborne 352/458 (76.9) 114/147 (77.6) 466/605 (77.0)\nFoodborne 113/328 (34.5) 9/101 (8.9) 122/429 (28.4)\nWaterborne 119/322 (37.0) 5/98 (5.1) 124/420 (29.5)\nOther (please specify) 11/60 (18.3) 5/ 25 (20.0) 16/85 (18.8)\nTime to symptom onset n = 626 (%) n = 171 (%) n = 797 (%)\nImmediately – there is no delay 42 (6.7) 1 (0.6) 43 (5.4)\n0 to 2 weeks 448 (71.6) 152 (88.9) 600 (75.3)\n2 to 4 weeks 80 (12.8) 12 (7.0) 92 (11.5)\nOver 4 weeks 10 (1.6) 2 (1.2) 12 (1.5)\nI don't know 35 (5.6) 4 (2.3) 39 (4.9)\nMultiple entries 11 (1.8) 0 11 (1.4)\nPerceived reason for quarantine of SARS-\nCoV-2-positive individuals n = 625 (%) n = 171 (%) n = 796 (%)\nTo help them get better 22 (3.5) 0 22 (2.8)\nTo prevent them from infecting others 430 (68.8) 124 (72.5) 554 (69.6)\nThere is no good reason for that 3 (0.5) 12 (7.0) 15 (1.9)\nOther, please specify 1 (0.2) 2 (1.2) 3 (0.4)\nI don't know 9 (1.4) 0 9 (1.1)\nMultiple entries 159 (25.4) 33 (19.3) 192 (24.1)\nDuration of isolation (if not admitted to a \nhealthcare facility) n = 625 (%) n = 171 (%) n = 796 (%)\nAs soon as coughing stops 5 (0.8) 0 5 (0.6)\n10 to 14 days after symptoms first started 314 (50.0) 136 (79.5) 450 (56.5)\nAs soon as they feel better 36 (5.7) 3 (1.8) 39 (4.9)\n21 days after symptoms stop 110 (17.5) 9 (5.3) 119 (14.9)\nFor asymptomatic cases: as advised by \nhealthcare guidelines 61 (9.7) 10 (5.8) 71 (8.9)\nThey do not need to be isolated 3 (0.5) 9 (5.3) 12 (1.5)\nI don’t know 28 (4.5) 4 (2.3) 32 (4.0)\nMultiple entries 71 (11.3) 0 71 (8.9)\nChanges in hand washing practices n = 615 (%) n = 167 (%) n = 782 (%)\nI wash/sanitise my hands more often 561 (91.2) 143 (85.6) 704 (90.0)\nI wash/sanitise my hands less often 13 (2.1) 0 13 (1.7)\nThere is no difference in how often I \nwash/sanitise my hands 18 (2.9) 23 (13.8) 41 (5.2)\nOther, please specify 2 (0.3) 1 (0.6) 3 (0.4)\nI don`t know 6 (1.0) 0 6 (0.8)\nMultiple entries 15 (2.4) 0 15 (1.9)\nAvoided visit to healthcare facility because \nof SARS-CoV-2 n = 594 (%) n = 161 (%) n = 755 (%)\nYes 171 (28.8) 60 (37.3) 231 (30.6)\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n11\nNo 353 (59.4) 70 (43.5) 423 (56.0)\nNot applicable/had no need to visit a \nhealthcare facility 70 (11.8) 31 (19.3) 101 (13.4)\nWould you have a SARS-CoV-2 vaccination? n = 587 (%) n = 161 (%) n = 748 (%)\nYes 482 (82.1) 79 (49.1) 561 (75.0)\nNo 36 (6.1) 55 (34.2) 91 (12.2)\nI don't know 69 (11.8) 27 (16.8) 96 (12.8)\n224\n225\n226 More frequent hand washing was reported across both countries (90.0%); however, a higher \n227 percentage of respondents in South Africa (13.8%) than in India (2.9%) noted no difference in \n228 their hand hygiene practices. Overall, 75.0% of all the respondents indicated their willingness \n229 to receive vaccination when it becomes available; however, the percentages were higher in \n230 India (82.1%) than in South Africa (49.1%). The most common reasons cited for apathy to \n231 vaccination were perceptions of rushed vaccine development and the futility of vaccines for \n232 what respondents considered a self-limiting flu-like illness.\n233\n234 Self-efficacy: perceptions of SARS-CoV-2 infection prevention measures \n235 Respondents’ perceptions and concerns about their ability to cope with SARS-CoV-2 infection \n236 prevention measures are presented in Figure 2, given their perceived knowledge and \n237 awareness of the pandemic and infection risks. More than half of respondents in each country \n238 reported that they have sufficient knowledge of SARS-CoV-2, understood available \n239 information on the pandemic, would know what to do or questions to ask if they or someone \n240 else contracted SARS-CoV-2, and have access to healthcare were they to become ill with SARS-\n241 CoV-2 infection, and would be able to cope with extended containment measures such as a \n242 lockdown. Compared to South Africa, more respondents in India reported concern over \n243 infection, its financial implications and associated stigma. On the intent to wear a face mask, \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n12\n244 8.6% and 26.2% of respondents in India and South Africa reported dissatisfaction with this \n245 measure while outdoors, respectively.\n246\n247 Figure 2: Respondents’ perceptions of self-efficacy in relation to coping with the   \n248 COVID-19 pandemic in South Africa (SA) and India\n249\n250 There was no statistical significance between hand washing and water supply (Table 3), as \n251 even those without access to water supply reported that they washed their hands more \n252 frequently since the pandemic (p = 0.2168 and p = 0.7970 in India and South Africa, \n253 respectively). Water supply showed a mixed relationship with employment as some full-time \n254 workers had no access to water. The test highlights a difference between participants in the \n255 two countries; p = 0.008 and 0.4471 for India and South Africa, respectively. \n256\n257 Table 3 Relationships between selected variables\nA. Is hand washing affected by water supply?\nIndia South Africa\nHand wash frequency Yes No Yes No\nWash more 476 79 140 3\nWash less 13 0 0 0\nNo change 15 2 22 1\nOther 2 0 1 0\nDon’t know 5 1 0 0\nMultiple 10 5 0 0\np-value 0.2168 0.797\nB. Is water supply affected by employment?\nIndia South Africa\nEmployment Status Yes No Yes No\nStudent 124 9 5 0\nPart time 27 8 11 0\nFull time 217 29 62 0\nSelf-employed 40 7 47 3\nUnemployed 101 20 12 1\nRetired 18 8 19 0\nOther 8 2 1 0\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n13\nLaid off 4 4 5 0\np-value 0.0008026 0.4471\nC. Is avoidance of healthcare facilities because of fear of COVID-19 contraction \ninfluenced by age?\nIndia South Africa\nAge Yes No N/A Yes No N/A\n<20 11 15 11 2 1 1\n20-29 83 147 42 4 4 2\n30-39 28 81 9 7 9 4\n40-49 24 49 4 21 18 12\n50-59 11 31 3 17 19 8\n60-69 10 19 1 8 14 3\n>=70 2 10 0 1 5 1\np-value 0.001451 0.9008\nD. Is avoidance of health care facilities because of fear of COVID-19 contraction \ninfluenced by employment?\nIndia South Africa\nEmployment \nStatus Yes No N/A Yes No N/A\nStudent 37 57 27 2 1 1\nPart time 12 20 1 5 3 3\nFull time 57 137 27 25 21 11\nSelf-employed 11 28 2 10 26 10\nUnemployed 31 79 5 5 6 1\nRetired 9 17 0 8 7 2\nOther 5 3 1 0 1 0\nLaid off 1 4 3 0 2 2\np-value 0.0002084 0.4076\n258\n259 Our results show that some respondents avoided healthcare facilities during this pandemic. \n260 Some participants in this study, particularly in India, reported avoiding healthcare facilities \n261 because of a fear of contracting the COVID-19 virus; this was affected by employment status, \n262 more in India (p = 0.0002) than in South Africa (p = 0.4076). \n263\n264\n265\n266\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n14\n267 DISCUSSION \n268 This study provides insight into the public’s awareness and perspectives of the SARS-CoV-2 \n269 infection and risks in two middle-income countries hard hit by the pandemic [6]. The aim was \n270 to gain some understanding of the knowledge and views about the pandemic, particularly \n271 when considering the expected roles that the public have in this pandemic regarding social \n272 distancing and infection prevention through hand hygiene, mask use and vaccination uptake. \n273 At the time of the study, these two countries were at different phases of the pandemic \n274 infection curves with no viable vaccines available. Although these data are somewhat dated, \n275 these findings add to the body of knowledge on the public’s perceptions of the pandemic. \n276 Also, how a better understanding of this information can be leveraged for improved infection \n277 prevention and behavioural interventions and promotions for this and the future infectious \n278 disease pandemics. Such knowledge will be helpful in infectious disease pandemic control and \n279 mitigation, including in the ongoing COVID-19 pandemic. The insight from this study can assist \n280 with measures to address continued vaccine hesitancy and inequity when many countries are \n281 dealing with a fourth or subsequent infection wave. \n282 From the onset of the pandemic, efforts have been communicated to inform the public of \n283 infection risks and required containment/mitigation measures. The need for public \n284 engagement and hygiene intervention, behaviour change, and consideration of socio-cultural \n285 aspects in public awareness initiatives in India and South Africa has been noted in the \n286 literature [10-14]. The volume of news media dedicated to the pandemic may also have \n287 served to provide education and awareness among the public. Conversely, it may have fuelled \n288 confusion and panic, particularly on the diverse online channels where unbridled and \n289 unverified evidence and opinions compete for attention with information from local and \n290 global health authorities.\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n15\n291 Survey respondents demonstrated awareness of the pandemic, with most identifying the \n292 primary routes of transmission, incubation period, symptoms of infection, and recommended \n293 measures for infection prevention and management of mild conditions, including the reason \n294 for and duration of isolation. Information on the pandemic was generally gained from \n295 traditional and social media, family and friends, and government websites. Respondents’ \n296 reliance on general and social media as sources of pandemic-related information highlights \n297 the role played by the media in pandemic containment and mitigation. \n298 The information landscape has changed extensively in the last three decades, prompting the \n299 need to address not only the SARS-CoV-2 pandemic but also its related infodemic [15]. While \n300 the main aspects of an infodemic refer to inaccurate and misleading information shared \n301 through digital and physical environments during disease outbreaks, disinformation refers to \n302 the deliberate spread of false information. In this pandemic, we are increasingly witnessing a \n303 growing infodemic driven by misinformation, including a worrying trend in the escalation of \n304 disinformation through traditional and social/digital media [16-18]. The role of the media, \n305 traditional and digital alike, in framing and rapidly disseminating information is evident in this \n306 pandemic, particularly when related to influencing behaviours and empowering individuals \n307 with the accurate information to make informed decisions regarding IPC [15, 19-21]. \n308 Family and friends were noted as sources of SARS-CoV-2 information by respondents in the \n309 survey. Word of mouth presented face-to-face or through various communication channels \n310 within families and among friends, though not specifically a media source, is an essential \n311 source of information. It is also a key route for spreading misinformation, mainly because of \n312 the trust between the source and the recipient. Thus, the prominence of influencers (in the \n313 community and on digital platforms alike) in disseminating pandemic-related information is \n314 highlighted. \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n16\n315 The findings of this study underscore the importance of various media as sources of \n316 information for informed decision-making among the public. It also draws attention to the \n317 relevance of social media, and family and friends, as sources of pandemic-related information \n318 for the public. Given the infodemic that has trailed the SARS-CoV-2 pandemic on all media \n319 [21, 22], there is a need for evidence-informed and timely communication in continually \n320 addressing pandemic-related misinformation and disinformation. Infodemic management is \n321 multifaceted, requiring different disciplines to address it. Beyond communication, factors \n322 influencing an individual’s behaviours may relate to external pressures, including the \n323 economy, politics, education, health literacy and religious or cultural beliefs.\n324 Some respondents in this study considered SARS-CoV-2 to be food- or water-borne. Such \n325 beliefs may impact infection prevention measures; while there has been research into \n326 transmission by these routes [23, 24], they have not been noted as primary transmission \n327 routes for the viral infection. Droplet and airborne transmission have been noted as some \n328 primary transmission routes, with the use of face masks a significant intervention in reducing \n329 the spread of the infection [25, 26].\n330 Across both countries, some respondents expressed somewhat reluctance to mask-wearing, \n331 despite their concern about contracting the infection, which may be related to the stigma or \n332 discomfort of masks. Stigma, known to influence/compromise infection prevention \n333 behaviours [27, 28], needs to be addressed, locally and globally, not only for the current \n334 pandemic but also for future ones, and improved adherence to optimised infection \n335 prevention practices. \n336 Among other options to reduce infection risk, hand hygiene has been prioritised in public \n337 health messages for pandemic mitigation [29]. Access to clean water is critical for hand \n338 hygiene and is among the tools to address and mitigate the impact of the pandemic, as \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n17\n339 highlighted in the literature [29, 30]. While water supply did not affect hand hygiene \n340 frequency among respondents, it highlighted a difference between study participants in the \n341 two countries. Infection prevention measures such as hand hygiene and physical distancing \n342 may pose a challenge in some LMIC (India and South Africa are examples), especially in under-\n343 resourced sections of rural areas or densely populated urban settings [29, 30].\n344 Isolation and quarantine of infected and exposed individuals are underlying measures for \n345 infectious disease control, though this may prove challenging. Responses to SARS-CoV-2-\n346 related isolation/quarantine duration reflect respondents’ perceptions of SARS-CoV-2 \n347 incubation. While there was an initial consensus on a 14-day isolation/quarantine period for \n348 infected/affected individuals, there have been shifts and debates on the optimum incubation \n349 period of the virus, hence, the duration of isolation and quarantine measures [31]. \n350 Respondents’ responses reflected this, more so in India, where discussions about extended \n351 isolation periods have been reported [32]. \n352 Lockdown measures instituted in various parts of the world following the spread of SARS-CoV-\n353 2 served as another infectious disease mitigation strategy. With the rise of infection \n354 transmission and the attendant lockdown measures, it was expected that individuals would \n355 have avoided visiting healthcare facilities. Some participants in this study, particularly in India, \n356 reported avoiding healthcare facilities because of a fear of contracting the COVID-19 virus; \n357 this was influenced by employment status, more in India than in South Africa. Employed \n358 participants may be more likely motivated to maintain good health or hesitant to confirm \n359 illness, for fear of losing money or work, resulting in fewer visits to healthcare facilities, than \n360 those unemployed. While lockdown measures can reduce patient presentation to healthcare \n361 facilities [33, 34], such a decline in presentation may also be associated with later \n362 presentations with more severe consequences. Initiatives are required to address gaps in \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n18\n363 patient care necessitated by public health promotion strategies such as lockdowns in this and \n364 future pandemics. \n365 Across the two countries, attitudes to the vaccination were positive. However, the country \n366 analysis showed this was driven by higher vaccine acceptance in India, with respondents in \n367 South Africa more cautious regarding COVID-19 vaccination. Reasons cited for hesitancy or a \n368 negative attitude to SARS-CoV-2 vaccination were related to mistrust in the vaccine \n369 development process and the futility of vaccines for what respondents considered a self-\n370 limiting flu-like illness.\n371 This survey was, however, conducted before SARS-CoV-2 vaccines were available. Hesitancy \n372 towards the SARS-CoV-2 vaccine had been noted earlier in the pandemic, fuelled by infodemic \n373 on communication channels and the public’s belief in SARS-CoV-2-related conspiracies [35, \n374 36]. The notion that the pandemic has been grossly exaggerated and reported, with \n375 unnecessary financial and other stresses on populations, was expressed by some participants \n376 who provided additional free text information. As the pandemic evolves, research to better \n377 understand infection and vaccine-related concerns among the general population is needed \n378 to support targeted and contextually appropriate strategies promoting vaccine uptake and \n379 optimised infection prevention behaviours. \n380 Among individuals with opposing opinions about vaccination, using social science methods to \n381 study underlying reasons and contexts for their views, along with highlighting the individual \n382 rather than the collective advantages of vaccination, may provide helpful and relatable insight \n383 [36, 37]. This could be particularly important when considered in light of recent research and \n384 noted factors that may influence vaccine perception and uptake [38-40]. More recent \n385 research has provided insight into dealing with vaccine-hesitancy as well as the challenges \n386 associated with anti-vaxxers [41]. Public health campaigns and vaccination promotions should \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n19\n387 therefore understand and leverage social listening techniques to comprehend public \n388 perceptions concerning communication gaps. A similar method of social listening should be \n389 developed for community and traditional settings to understand why various beliefs and \n390 behaviours related to COVID-19 emerged.\n391\n392 STRENGTHS AND LIMITATIONS\n393 Our study provides unique insights into the public’s attitudes and practices across two LMIC \n394 during the early stages of this pandemic. The findings are subject to some limitations, which \n395 should be considered in its interpretation. \n396 First, being a cross-sectional study, the relevance of the findings may change over time and \n397 with interventions, especially as subsequent waves of COVID-19 have been reported. Second, \n398 the online distribution of the survey and the limited paper version may have limited its reach, \n399 particularly under-representing individuals from diverse socio-economic levels. Third, data \n400 collection across both sites did not rely on the same methods, given the COVID-19 restrictions \n401 at the time of data collection, which likely influenced the sample sizes across the sites. Sample \n402 size may also have been influenced by survey fatigue, challenges with Internet access in LMIC, \n403 and other limitations associated with accessing and participating in the survey at the time of \n404 the survey roll-out. \n405 Survey respondents are therefore not representative of the public in either of the two \n406 countries, limiting the generalizability of findings. In addition, this survey was conducted \n407 between September and December 2020, when both countries were at different phases of \n408 the SARS-CoV-2 pandemic. The differences in experiences across the countries may have \n409 influenced the responses provided. \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n20\n410 Nevertheless, this paper fills a gap in the knowledge, awareness and attitudes of the public in \n411 India and South Africa towards IPC practices in the context of COVID-19 within the first year \n412 of the pandemic. It will be beneficial for charting public understanding and perception of the \n413 COVID-19 pandemic and provide informative data that can be employed for public \n414 engagement in other infectious disease control and mitigation across both sites and similar \n415 contexts. While this research presents the data for each country separately, it is not its \n416 intention to make any statistical comparisons between participants in the two countries. \n417 Despite that, the individual test on how employment affects water supply and the avoidance \n418 of healthcare settings during lockdown provided some insight on differences between \n419 participants in the two countries. Thus, the need for pandemic mitigation efforts to consider \n420 differences in context and subjects for the delivery of context-specific and appropriate \n421 interventions is highlighted.\n422\n423\n424 CONCLUSIONS\n425 This study presents socio-economic and demographic data, which may influence public \n426 awareness and behaviour and further be explored in pandemic mitigation initiatives among \n427 the public in both countries. Survey respondents correctly identified public health promotion \n428 measures for SARS-CoV-2. Reported disinclination to mask-wearing and reported hesitancy \n429 for the uptake of SARS-CoV-2 vaccination highlight gaps that can be addressed for improved \n430 pandemic mitigation efforts. Further research to explore the outlook towards mask use and \n431 vaccination across both countries can provide more insight on factors influencing infection \n432 prevention and vaccine apathy. Vaccination campaigns should consider robust public \n433 engagement and more targeted communication strategies using tactics like social listening, \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n21\n434 with multimodal, participatory online and offline initiatives to address the infodemic that \n435 drives public concerns. Furthermore, this can contribute to developing a better understanding \n436 of the driving force behind vaccine hesitancy among different populations. \n437\n438 Acknowledgements \n439 The authors express appreciation to all survey participants and members of the public who \n440 participated in the review of or provided feedback on the survey tool, and to Ms Jean Fourie \n441 for review and editing of the manuscript.   \n442\n443 Author contributions\n444 OM conceptualised and wrote the initial protocol for the study, with additional input and \n445 revision from CB, VC, HL, RA, SSingh and overall oversight by EC and MM. OM, SSurendran \n446 and EC coordinated the data collection with input from NZ, SSurendran, VN, and FE \n447 contributed to data capturing; OM, FE and ES contributed to the data analysis. OM wrote the \n448 first draft of the manuscript, with input from SSurendran and oversight from EC and MM. All \n449 authors contributed to subsequent revisions and approval of the final draft. \n450\n451 Funding sources\n452 The work was supported by the Economic and Social Research Council (ESRC) as part of the \n453 Antimicrobial Cross Council Initiative supported by the seven UK research councils, the \n454 Global Challenges Research Fund (GCRF) as part of the ASPIRES project \n455 (https://www.imperial.ac.uk/arc/aspires/), the National Institute for Health Research, UK \n456 Department of Health [HPRU-2012-10047] in partnership with Public Health England and \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n22\n457 the National Research Foundation of South Africa (Grant Number: 129755). The funders did \n458 not have any role in the study design and conduct, review or approval of the manuscript, or \n459 the decision to submit the manuscript for publication.\n460\n461 Declarations \n462 Ethics approval and consent to participate\n463 The study was approved by the relevant human research ethics committees at the Amrita \n464 Institute of Health Sciences, Kerala, India (Ref: IRB-AIMS-2020-232) and the University of \n465 Cape Town, South Africa (Ref: 311/2020). \n466\n467 Competing Interests\n468 The authors declare they have no competing interests.\n469\n470\n471\n472 Patient and public involvement\n473 A patient advocate and public engagement specialist/civil society champion was involved in \n474 the design of the study material and also contributed as an author. Members of the public \n475 participated in the review of the survey tool and provided feedback for its modification. 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SAMJ. 2022:112(1). http://dx.doi.org/10.7196/SAMJ.2022.v112i1.16208  \n621\n622\n623\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint \n\n . 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